Putting SARS in Historical Perspective





Dr. Markel is the George E. Wantz Professor of the history of medicine, professor of pediatrics and communicable diseases, professor of public health,, and director of the Center for the History of Medicine at the University of Michigan. This article is drawn from his new book, WHEN GERMS TRAVEL: SIX MAJOR EPIDEMICS THAT HAVE INVADED AMERICA SINCE 1900 AND THE FEARS THEY HAVE UNLEASHED, which was published by Pantheon Books on May, 11 2004.

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The waves of hysteria inspired by last year's SARS epidemic, not to mention those created by the more quickly contained annual spread of influenza this past winter recalls President Harry Truman's pithy observation that “there is nothing new in the world except the history you don't know.”

Although recent phenomena, SARS, avian influenza, garden-variety influenza, and even briefer brushes with more exotic emerging infectious such as West Nile Fever and monkey pox have more in common with epidemics of the past than most realize. Indeed, if one were to design a course for college freshman entitled “Epidemics 101,” one hardly need go further than a Lexis-Nexis search of last year's media frenzy over Severe Acquired Respiratory Syndrome to compile a superb reading list.

Like so many"great plagues" of the past, the SARS crisis presented the many of the hallmark features framing the social response to epidemics including its seemingly sudden rise from nowhere; an easy transmission from one person to another; the dragnet of cases; its inhibition by one country or social group attempting to obscure the outbreak; the scapegoating of a particular social group perceived to carry the infection in question; the microbe's spread abetted by our thirst for rapid, worldwide travel; intense media coverage; calls for quarantines; and, of course, the remarkable levels of panic during the rise of the epidemic that quickly fell as the numbers of new cases diminished.

In fact, all these elements have been essential aspects of epidemics, ranging from the Black Plague of the fourteenth and fifteenth centuries, the cholera epidemics of the nineteenth century, all the way to the stunningly lethal influenza pandemic of 1918 and the early years of AIDS. Parenthetically, another plot twist in the history of epidemics that has appeared in the past but appears to have the potential for a larger role in the future has been the perverse threat by terrorists inflicting the terror of infection, as we saw with the anthrax and smallpox scares during the year 2001.

But, to my mind, the most troubling paradox of epidemics both past and present is the dichotomy between the brief, ubiquitous and panic-stricken attention we pay to the new infections that kill few in spectacular fashion, like SARS, and our apathetic responses to familiar scourges that literally plague humankind everyday.

Compare the level of attention we gave the approximately 8,000 people who died of SARS last year to the 1,500 people who died of some type of contagious disease in the last hour alone. Malaria, AIDS, tuberculosis, measles, diarrheal diseases, to name but a few common killers, have become all too familiar to our media-glazed eyes and our responses, to harken back to the ancient physician's diagnostic rubric, have become all too phlegmatic.

What distinguishes the complex dance between humans and microbes today from eras past, however, has much to do with the remarkable advances science has made in the understanding and amelioration of infectious diseases. SARS is a striking example of this trend. A year and a half ago, no one had ever heard of it. Less than two weeks after the first cases reported in Hong Kong, scientists have not only identified its cause, they have even dissected out the virus's genetic structure, and are well on the way of developing a series of diagnostic tests and, hopefully, means of treatment.

Yet even these remarkable strides in the science of public health have had unintended consequences. The quick detection and containment of a contagious threat, followed by premature declarations of victory, often give rise to a collective underestimation of the unpredictable and remarkable power of infectious diseases. These successes engender a false confidence that the eternal struggle between human and microbe has been won rather than temporarily stayed. Ironically, just when public health departments are working at their best, there is a strong temptation to cut their budgets.

In reality, only the global community can make inroads in responding rapidly to new epidemic crises such as SARS and containing older ones like AIDS, malaria, and tuberculosis. All of us must accept that the public's health is everyone's problem and responsibility, no matter where today's infectious “hot zones” happen to be. We must back that acceptance with a constant stream of financial and social support even in times of relative infectious quiet.

The good news is that many of the world's truly significant infectious killers are preventable or, at least, treatable. We could prevent some 30 million cases of measles (and the 1,000,000 deaths it causes each year) by vaccinating every child in the world against it at a cost of about 25 cents per vaccination. We could prevent nearly 2 million deaths a year from diarrheal diseases (most of them children) by making sure that everyone in the world has daily access to clean water; at present, more than 1.5 billion do not. With adequate mosquito control, we could significantly reduce the millions of deaths caused each year by malaria, yellow fever, dengue fever, and West Nile virus.

Economists on behalf of the United Nations have estimated that if every citizen of every wealthy nation of the world donated approximately fifteen dollars per year, or 1/10 th of a percent of the wealthy nation's Gross National Product, to preventing and treating epidemics in the world's poorest nations in an internationally coordinated fashion, 21,000 lives would be saved, not to mention millions of dollars in lost productivity, every day.

History teaches us that epidemics are a fact of life with recognizable patterns and pitfalls. Although the World Health Organization made tremendous strides in containing the SARS epidemic last year, we must recall that it is largely a voluntary organization without police powers or real authority. This was sadly demonstrated by China 's reluctance to announce cases of the infection as early as November of 2002. For countries struggling under immense poverty, public health surveillance and other preventive measures that contain the plethora of contagious ailments that kill on a daily basis simply cannot be attended to without real and lasting help from the wealthier nations of the world and a global approach to their containment.

Before SARS joins the growing list of once feared and now ignored epidemics, and a new microbe rises to take its place, we should seize the opportunity to develop permanent and accountable global public health mechanisms to prevent the contagious crises that are certain to arise and linger in the future.

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Jonathan Dresner - 4/29/2004

Well, you misinterpreted me a little, but we're basically in agreement. Your point about the tentative nature of our recent gains in lifespan expectency is interesting: we tend to think of these things as "done" but technology, as with anything in history, does not proceed in a linear fashion, and when people are making individual choices, may not proceed at all.

I'm well aware that the public health warnings are quite factual (usually; sometimes we make mistakes), particularly about anti-biotic resistant bacteria. My point is that the real science gets conflated in the public mind with the fictions.


E. Simon - 4/28/2004

Jonathan,

"Alarmist" or not, the danger to which you allude with regards to antibiotic-resistant staph (and nearly everything else) is quite real. The enormous leaps we were able to make in using antibiotics to treat what were previously some of the most pervasive killers are quickly becoming obsolete not only in most if not many cases and communities, but spreading. It would be a minority opinion in the field of infectious diseases to suggest that what you, as an historian, know to be real advances in lifespan from decades ago, are secure in this age - given the pattern of microbial life cycles and evolution patterns in the face of very real selection pressures.

Forgive me if I have misinterpreted the thrust of your post, but my impression is that you are admonishing against an alarmist reaction to the threat of rarer microbes at the expense of ignoring the consequences of our actions on more common pathogens. Indeed, the SARS virus evolved from a common cold virus - which is incidentally, impervious to, and untreatable by modern therapies. In this instance, poor hygenic practices (such as the acceptance of spitting in public in China to the point of tolerating pits of phlegm on the streets) are often cited as a likely contributing cause in facilitating the evolution of this germ. Advances in hygeine may predate antimicrobial therapy in reducing the threat and incidence of infectious disease, but not by much in a long-term historical perspective. (Or apparently perhaps not at all).


Jonathan Dresner - 4/28/2004

Part of the responsibility for our complacency about endemic disease and our recurrent panic over "new" diseases has to do with the dramatization of epidemic disease. Not Satre, so much, but Robin Cook, Stephen King (The Stand, in particular) and many lesser known practitioners have created a sense of dread that a new disease might be worse than the old diseases. They take legitimate science, existing diseases like ebola and past epidemics like Swine Flu, and make it as frightening as possible.

The plausibility of these fictions is highlighted by public health warnings about antibiotic resistant staph, and marketing of products like anti-bacterial underwear, etc. so that the dramatists are seen as only slightly alarmist. Then, of course, when the words "new disease" and "highly infectious" cross the news ticker, everyone thinks of the fictions, not the much more likely facts.

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